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Newman Jr., Ira 61/19/2016 17:16 15184895632 -"rr, TEBBUTT FREDERICK r4 PAGE 61 NEW YORK STATE DEPARTMENT OF HEALTH Vital Records Section Burial . Transit Permit % ,A '"mil_ Name First Middle Last Sex IRA J. NEWMAN, JR. MALE Date of Death Age If Veteran of U.S.Armed Forces, • 01/15./2016 85 War or Dates YES I-. Place of Death Hospital, Institution I Z City,Town or Village City of Albany _ or Street Address ALBANY MEDICAL CENTER 13//j~Manner of Death Natural �® Cause ❑ Accident ❑ Homicide ❑ Suicide ❑ Undetermined ❑ Pending Circumstances Investigation W Me• dical Certifier Name Title © STEPHANI WANG MD Address 43 NEW SCOTLAND AVE ALBANY NY 12208 j . Death Certificate Filed District Number ' Register Number City,Town or Village City of Albany 101 137 Date Cemetery or Crematory E Burial 01/19/2016 PINE VIEW CREMATORIUM [' Entombment Address Cremation QUEENSBURY NY 12804 Date Place Removed " Z Removal and/or Held i Q E and/or Address T _ Hold 1(A. 0 Date Point of - a Transportation Cl)I ❑ By Common - _ Shipment p Carrier Destination ❑ Date ' Cemetery Address Disinterment Date Cemetery Address ❑ Reinterment 1 _ j Permit Issued To Registration Number • Name of Funeral Home SINGLETON SULLIVAN POTTER FUNERAL HOME 01596 Address 407 BAY ROAD QUEENSBURY NY 12804 Name of Funeral Firm Making Disposition or to Whom Remains are Shipped, If Other than Above Address W la- Permission is hereby granted to dispose of the human remains descrjb aboye as indicated.. ndicated. J Date 01/15/2016 Registrar of Vital Statistics / CO �- i t , j J r. �C Jed,_ Issued (signature) District Number 101 Place City of Albany, NY I certify that the remains of the decedent identified above were disposed of in accordance+ with this permit on: I Date of Disposition 1/ZZ t i 16 Place of Disposition 4 tt U4,z_., ( Torte u.I (address) 7 w rn . O (Section) (lot number) (grave number) 0 Z Name of Sexton or Person in Charge of Premises S;kOfb- �GA (please print) Signature_____ (,./1. 14 Title jet 1I (over) DOH-1555{02/2004)